Care Assured - If You Can Pay

2006 photos of Lehigh Valley Hospital, currently undergoing expansion at its main site in Salisbury Township. (Frank Wiese/The Morning Call)

Jeffrey G. Fleishman and Ann WlazelekOf The Morning Call

A revolution is sweeping across the health care industry, and it has turned medicine into big business. Bigger health systems mean better care, say some analysts. Others predict a crisis in which compassion is replaced by Wall Street toughness. Morning Call reporters Jeffrey G. Fleishman and Ann Wlazelek examined the trend in a three-month investigation encompassing more than 100 interviews and review of hundreds of medical documents and studies.

A humid breeze blows through the back kitchen door and shakes the crayon- colored pictures that hang on Margaret Jones' refrigerator like tacky Christmas ornaments. Wheel Of Fortune is on the television in the living room and Vanna White is turning letters.

But game shows are not on Margaret Jones' mind. She has cancer, a son with a rare nervous disorder and no health insurance.

She has learned to live with the cancer and her son's condition: factors of fate that nothing, perhaps not even the most devout praying, can alter. But not having health insurance hurts her pride, especially when she sits for hours in hospital clinics surrounded by the blank faces of other mothers rocking their crying babies. She is surrounded by "unfortunates" and when she looks into the eyes of doctors and nurses she realizes she too has become unfortunate.

Her 11-year-old son has Tourette syndrome, a disorder that causes involuntary twitching in his body. Sometimes the boy has "verbal tics" in which he uncontrolably blurts out obscenities.

Her husband, Brian, is a welder and can find work only sporadically. So their lives shift from short times of stability to periods of piling bills and a forced reliance on medical assistance. The days Brian is not working he is out looking for work.

"When welding was a good profession around here my husband was working all the time and we were on Blue Cross and Blue Shield. But now we have nothing," said Jones. "Until Brian began getting laid off I never imagined what these poor people go through. It's terrible.

"Something needs to be done . . . Once when we were back on government assistance I went into the supermarket with my food stamps and I heard people remark: 'Why don't they get a job? ' But they don't understand that we can't."

But Jones found out about perhaps the harshest reality that the poor face when last December she tried to get admitted to Allentown Hospital for kidney and intestinal pains. Her husband wasn't working and the family was not yet on medical assistance.

"They weren't going to admit me because we had no insurance and no way to pay the bill," said Jones. "I started to cry and got hysterical. We told the woman we applied for medical assistance and she said, 'But what if you don't get it? ' Then she said, if I was admitted we'd have to put some money down before I left the hospital. "

As she sat in the admitting office Jones said she knew her family had no way to pay the bill. "The bill collectors were already knocking at the door. The electricity was shut off and the collectors were threatening and cajoling us," she said. "I would try to pay $5 or $10 on the bills we owed and sometimes we ate macaroni for dinner so we could pay a bill. "

Several hours later, after verifying that Jones was due to get medical assistance, the hospital admitted her. "But they kept reminding us and said we'd be liable for the bill if medical assistance didn't come through," Jones said. "They said they'd have to put a lien on our home. " The bill was about $5,000 and was covered by medical assistance. "The hospital socks you for everything . . . even a little pill was $10. "

Kerri Puskar, acting director of public relations for Allentown Hospital, said the institution does not harass people for money. When a poor person comes to the admitting office, she said, the hospital first tries to see if he or she qualifies for insurance. If not, the hospital attempts to get the individual on medical assistance. If this also is unsuccessful, Puskar said, the hospital then picks up the bill.

"We do not deny anybody treatment," Puskar said. "We've had people come in here from foreign countries with no insurance and we treated them for free. " When asked about Jones' version of how she was treated, Puskar said, "Everybody has their own perceptions. But they are not pressed for the money. "

"No discussion is held about any type of collection procedure," said Harriet Samuels, Allentown's director of patient representatives. "I would like to point out that being admitted to a hospital can be a confusing and frightening experience and there are times when misunderstanding s take place. "

When informed that the hospital officials said they did not mistreat Jones in the manner she claimed, Jones responded: "They might deny all this stuff but I went through it. "

Jones is one of 35 million Americans with minimal or no medical insurance coverage. She is an example of what the working poor encounter both mentally and emotionally when they seek medical care.

Many of the working poor formerly had high paying blue-collar jobs with full medical benefits. But economic recessions put them on layoff or forced them into lesser paying jobs that offer minimal health coverage.

Yet, like Jones, many believe that medical care is a birthright.

Jones said she now realizes that medical care is a birthright only if you can pay.

Statistics show that community hospitals nationwide - in efforts to avoid costs in caring for the poor - are sending uninsured patients to less adequate county hospitals. It's called "patient dumping. "

A recent article in Jama Magazine, the journal of the American Medical Association, revealed that in Chicago there were 1,295 cases of patient dumping in 1980. That figured jumped to 5,652 in 1984.

There are no county hospitals in the Allentown area and for the most part the poor are being treated at community hospitals, said Alan Jennings, deputy director of the Community Action Committee of the Lehigh Valley.

But a recent survey done in Allentown reaffirms state findings that treating the poor appears to be a low priority among physicians and hospitals, said Allentown Health Director Gary L. Gurian, who commissioned the University of Pittsburgh to do the survey for the city.

Seventy city doctors, or 37 percent of the 190 surveyed, indicated they do not accept Medicaid patients, according to the study. And of the 53 percent (101) who said they "generally" do see poor patients, most saw fewer than 20 percent who paid through Medicaid. Only 10 physicians reported seeing 50 percent or more Medicaid patients in their practices.

Gurian said Allentown has created "medical care ghettos" where the poor are relegated to clinics operated by hospitals, the city Health Bureau and other community organizations like the Visiting Nurses Association.

"It is a haphazard clinic system with inherent problems of access, quality and cost," Gurian said. "That is why the Health Bureau is a strong proponent of a community medical and dental care center for low income families. "

The bureau itself has had difficulty obtaining neurologic and allergy evaluations for poor children from specialists at hospital clinics as well as from physicians in private practice, Gurian said. In addition, when the Health Bureau asked two new women's health care centers in Allentown to offer mammography screening and other women's services for Medicaid patients both centers refused, Gurian said.

Interviews with Jones and others in similar situations reveal that although many poor Americans are caught in the middle of today's medical revolution they don't understand its cause. They still believe in the community hospital of 30 years ago, traditional health insurance and compassionate doctors. It was then that hospitals could afford to be more generous.

"Hospitals in those days were compensated by insured patients . . . at charges in excess of full cost," said Uwe E. Reinhardt, a professor of political economy at Princeton University. "It mattered little when uninsured patients failed to pay their bills. "

But that era has changed. With funding cutbacks and stiffer competition between hospitals, doctors and insurance companies, hospitals are torn between continuing to care for the indigent while attempting to survive in a free market atmosphere.

"In the current marketplace you can't concentrate too much on providing indigent care or you'll go out of business," said Jan Schulman, spokeswoman for the American Hospital Association. "And if you go out of business you jeopardize access of care to the whole community. Hospitals are caught between a rock and a hard place. "

But Jones has little sympathy for hospitals.

"You know I think to myself the hospitals are lying," she said. "I chuckle when I see a sign that says 'we will not turn you away. ' That's crap. And if they don't turn you away they treat you like a subhuman person. "

What's the solution? For Jones it is simple:

"More doctors have to be willing to take people on medical assistance; hospitals need to be more sympathetic to people and hospitals should concentrate on helping poor people rather than making profits . . . The profits they made last year made me mad, very mad, and I'm not the only one."